Tricare Philippines Newsletter 12008
Current Understanding of the Provider Certification Process
The TRICARE Management Activity (TMA) added the Philippine unique requirement that claims would only be paid for care provided by certified providers. The stated purpose for this requirement was to insure that only care provided by licensed and properly trained providers would be considered when processing claims. This process was implemented in reaction to some military retirees and local providers submitting claims for care not received.
In reality, for many beneficiaries it means care provided by legitimate licensed and trained providers is also denied. Not because the care is unnecessary or the provider is not a legitimate licensed provider but because a “process” was not completed. There are other approaches that TMA could have used to accomplish the same end and at lower cost but they contracted with a U.S. company, International SOS (ISOS) to develop the process for them. Under TRICARE Standard, TRICARE For Life functions as Standard overseas, the major advantage as advertised by TMA is freedom of choice to chose providers of your choice and this option is available to every other beneficiary overseas and in the states; only in the Philippines is this restriction applied to Standard.
TMA refuses to explain the process except to say it is proprietary and therefore confidential and cannot be discussed with beneficiaries in spite of multiple written and verbal inquiries. Even the reason for a provider denial is considered proprietary and will not generally be released. However we have gathered major portions of the process through discussions with current and former ISOS employees, and by using our group of retirees to question their providers, both those certified and those reported as not certified, to develop, what we feel is a fairly accurate picture of the actual process.
Why should we know how it works?
It is important to understand the process in order to understand what happens that causes thousands of claims to be denied for legitimate care provided by trained, licensed and qualified providers. With this understanding we are then better able to overcome or circumvent these denials in order to get these legitimate claims paid.
So what is the process?
A beneficiary sees a local provider that is not certified and submits a claim. When Wisconsin’s Physician Service (WPS) receives the claim they check the providers against the certified provider list. If the provider is not certified they notify ISOS and request a certification. WPS will then hold the claim for 90 days while ISOS completes the certification.[i] When ISOS completes the certification they notify WPS who then proceeds with processing the claim. In the event that ISOS denies certification or the 90 days expires without feedback from ISOS, WPS will deny the claim using one of two reason codes, 018 PROVIDER NOT TRICARE AUTHORIZED FOR THIS SERVICE or 135 PROVIDER IS NOT TRICARE AUTHORIZED REQUESTED PROVIDER CERTIFICATION INFORMATION NOT RECEIVED. Why one code or the other are used has never been explained to us.
The general process used by ISOS, as reported by physicians, other providers and ISOS employees. First they check their files for the provider. If they find that in the past the providers declined certification they simply notify WPS that the provider is not certified and close the case. Otherwise the process is to send the provider a letter informing them that ISOS wants to certify them for TRICARE and asks them to agree to that certification. An alternative method used sometimes in the Manila area is to call the provider and obtain this concurrence to certification. If the provider declines to be certified ISOS annotates the file and notifies WPS. If they agree to certification ISOS schedules a time to visit the provider where they obtain copies of licenses, tax certificates and confirm that the providers has a physical office at the location. (Because of a recommendation by ISOS and concurrence by TMA physicians have to be certified by physical location instead of being certified as an individual so a single provider may have multiple certifications.) Once this is complete and they are certified ISOS notifies WPS and the claim process continues. If they are not certified ISOS also notifies WPS and the claim is denied and returned for one of the reasons stated above.
That’s the official process however there are a number of issues we have found surrounding this process that can cause claims to be denied.
Our members have reported that ISOS has taken as long as seven months to actually contact their provider and certify the provider.
Providers decline certification because they heard that there was a fee, are afraid of being charged with fraud by TRICARE or they have no idea why they are being certified.[ii]
- ISOS will not contact a provider that previously declined certification but simply notify WPS that the provider is not certified.
Providers have told beneficiaries that nobody contacted them from ISOS when the beneficiary, whose claim was denied, questions the provider as to why he declined certification.[iii]
WPS denies a claim after 90+ days because ISOS has not responded but later ISOS notifies WPS that the provider is certified but they take no action to reopen the denied claim(s).[iv]
Wouldn’t it be better if we could request certification before we see a provider?
This approach was recommended by us and approved by the Pacific area office of TRICARE more than five years ago and was in place for approximately one year until TMA in Washington discovered the new process and stopped it claiming it was not required and unnecessary. Inquires requesting reconsideration have been ignored.
What can we do to help insure a provider is certified and we get paid?
When you see the provider
If the provider is a hospital, pharmacy or something similar see the administrator or owner and explain that you and other US military retirees and their families would like to use their facility and explain that we have an insurance program known as TRICARE. Explain that once you use any of their services and submit a claim that within a few months, it is supposed to be within 90 days but we know ISOS has taken as long as seven months, that a company, International SOS, out of Manila will send them a letter asking if they want to be certified and listing some requirements. Ask them to agree to this request and see if they will agree and hopefully they will. Point out to them that if they agree to certification, it does not obligate them to do any additional requirements but it will allow you to get partial reimbursement. Explain there is a little cost to them to copy a few documents and some time to complete some forms. (If this is a physician there may be significant additional expense if they have to register an additional office with the Philippine BIR. ISOS requires each physical office be registered which is not necessarily done by many physicians.) Also tell them that by agreeing to certification he is not agreeing to file claims. (I mention this because in the past ISOS staff has insisted that a hospital being certified must submit claims and the hospital involved refused certification because of it.) In the case of a physician address this to him directly.
Try to determine if ISOS has ever asked them in the past to be certified. They may not know the answer but it is best to ask since ISOS will not even try to certify them if they have. If they declined in the past you will have to convince the provider to call or mail ISOS requesting to be certified. It may help if you agree to pay for the call or the postage on the letter and even offer to prepare the letter if necessary.[v]
Then follow-up with the doctor or his staff after a few months to see if ISOS has contracted them and also so they don’t forget why they are being contacted.
If the provider you want certified is a hospital, the next time you have to fill a prescription or need a lab test use the facilities at the hospital and file a claim. This will get the process started. With a hospital it is better to start the process with a small claim like a prescription than an inpatient stay as the process can take months and waiting for an inpatient claim will cause your money to be tied up during that time. Also if the hospital is denied or declines certification the loss will be much less.
When you submit the claim
Make sure you include the full name, address and specialty of the provider with your claim. If the provider is certified at another location include that information in your narrative as it may help expedite the process by alerting ISOS to the previous certification as they will already have many of the required documents from the previous certification.
When your claim is denied for non-certification
If after all of this your claim is still denied for non-certification, it is not over yet.
The first thing to do is look at the time between when WPS started processing your claim and when it was denied.[vi] If the number of days are 15 or less the most likely reason for denial is your provider had previously declined certification.[vii] If this happens attempt to speak to the provider and explain that it appears they previously declined certification and try to get them to agree to send a letter requesting certification as addressed above. If you are sure your provider will now agree to certification an alternative approach is to follow the guidance on sending a request to WPS as discussed below in the “If all else fails” section.
If the number of days between the start of claims processing and denial exceed 15 days one of the following reasons is most likely.
- They were contacted but declined to be certified.
- ISOS was not able to find the physician, see End Noteiii
- ISOS still hasn’t gotten around to contacting and certifying the provider.
The first steps to take.
- Contact the provider and verify that they were contacted by ISOS.
- If they were contacted confirm they either a) declined certification or b) agreed to certification.
If they agreed to certification but it has only been a week or so it is likely the process had not completed but will in a few weeks. In that case check the Certified Provider list at each update to determine if the provider has been listed. Once the provider is listed, email WPS and request the claim be reconsidered since the provider is now certified. Alternatively resubmit the claim but indicate in the narrative that the provider is now certified or the claim maybe denied as a duplicate claim.
If they were contacted but declined to be certified there is little you can do unless you can persuade the provider to change their mind. If that happens then the actions addressed above in contacting ISOS must be completed.
If the provider wasn’t contacted you can wait and watch the Certified Provider list at each update to see if they are finally certified. This can take a long time if ISOS has delayed certification for whatever internal reason; our past experience has shown that in some cases ISOS takes as long as seven months to get around to doing a certification. While you are waiting also check back with the provider from time to time to confirm if they were visited by ISOS and to keep the certification process in their mind. Again once the provider is listed, email WPS and request the claim be reconsidered since the provider is now certified. Alternatively resubmit the claim but indicate in the narrative that the provider is now certified or the claim maybe denied as a duplicate claim.
If all else fails
If all else fails or if you don’t care to make the effort as addressed above there is one more option.
The TRICARE Operations Manual, Chapter 24, Section 14 mentions how ISOS is supposed to stack certifications for processing:
2.3.4 The TOP contractor shall use the following guidelines for prioritizing certification of Philippine providers as follows:
126.96.36.199 Reviewing new providers.
188.8.131.52 Reviewing the TOP contractor's current certified provider files.
184.108.40.206 Reviewing non-certified providers on claims which have been denied by the TOP contractor and the beneficiary/provider has followed-up on why the claim was denied.
220.127.116.11 Reviewing non-certified providers on claims which have been denied by the TOP contractor and the beneficiary/provider has NOT followed-up on why the claim was denied.
While we have our doubts ISOS complies with the last paragraph, 18.104.22.168, the beneficiary can invoke the review outlined in paragraph 22.214.171.124 by inquiring as to the status of the provider’s certification with WPS. Our information suggests that ISOS is supposed to relook their previous action and in cases where they simply notified WPS that the provider was not certified due to a previous declination, they will re-contact the provider. But since TMA claims these processes are proprietary and confidential we have not received an official confirmation. When making this inquiry, be sure to make reference to the claim number of the denied claim and quote the information above and include a request that WPS respond with the results of this review. These requests may be mailed, faxed or sent via the secure email process via your WPS account.[viii]
Additional Information on Certification requirements
In some instances a physician maybe covered by a hospital’s certification. For a physician to be paid under the hospital certification they have to be on the paid staff of the hospital and performing those duties which became part of your bill. In other words they are paid by the hospital and do not bill separately. This can be confusing in the Philippines because physicians routinely ask the hospital to collect their fees at the same time they collect their final payment and sometimes a physician might work privately and also for the hospital at different times. But in general there are two instances where the physician is covered by the hospital certification. The first and most common are radiologists and pathologists who read, interpret or certify these or other ancillary services. The second is where a procedure is accomplished using a major piece of equipment owned by the hospital where they either charge a single fee for the service which includes physician fees[ix] and in the eyes of WPS who, using U.S. medical billing standards, it appears to be what they know as "global" billing or when the bill itemizes the fees but only says "physician" or "anesthesiologist" on the bill. Again WPS probably pays these based on U.S. medical billing standards and not necessarily on the reality of what is really going on here.
We understand the two cryptic denial codes, listed above, provide no usable information as to the real reason the provider was not certified and therefore why your claim was denied. About 5 years ago we addressed the need to add additional denial codes that specifically addressed the certification status that resulted in the denial. The response from TMA was the cost was prohibitive to add new codes. Recently we personally addressed the issue again to a senior staff member of WPS who seems to understand and agree with our concerns. However, feedback indicates he is also getting the same response from TMA that it is cost prohibitive but he is continuing to look into it. The troubling thing about the TMA response is we know that over the last 5 years a number of new reason codes have been added because, apparently TMA wanted them added, and cost apparently wasn’t a factor. So we are not sure if we’re making much progress on this front but will continue to pursue it.
The next newsletter will address issues with using the Certified Provider list, including understanding how it is put together, issues with the many data entry errors and how to overcome some of them and alternative sources of information.
Share this newsletter with other beneficiaries
Forward this newsletter to others you feel might benefit from them so they can sign up as well. If you represent an RAO or service organization let your members know so they can sign up. Sign up link
If you are on Facebook share this newsletter with your friends.
[i] The current TRICARE Operations Manual specifies 45 days but TMA finally realized that their contractor was not completing certifications in that timeframe so instructed WPS to hold claims for 90 days. This information was obtained via email from a TMA employee.
[ii] Providers were previously charged by ISOS for certification and charged for what they were told was training to submit claims. This was prevalent in the past but apparently not done today. However providers still shy away from certification because of this. ISOS placed notices on the Certified Provider webpage stating there is no charge in an attempt to overcome their past. The TMA Program Integrity Office routinely accuses providers of fraud when in reality all the provider did was comply with local medical industry standards or not understand the complex U.S. medical coding process. TMA openly claims 64% of all Philippine providers are under prepayment review for fraud. These constant charges made against local providers causes many to avoid any association with TRICARE. TMA and ISOS refuse to tell a provider that they are being certified because a specific TRICARE beneficiary saw them because they claim it is a violation of patient privacy.
[iii] Beneficiaries have reported many instances of this happening on a fairly routine basis. Most often it appears that the ISOS employees become confused as to the location of a provider and simply give up instead of using some initiative. One example was a provider who moved his office to another building down the street. It was likely that a physician with a clinic near the provider’s old office would have known where he moved. Secondly the provider was already certified at another location and a simple phone call to the other location could have resolved the issue. Instead the provider was classified as not certified. In another example the employees went to an annex of a large hospital where they couldn’t find the doctor’s offices. In actuality the two doctor’s offices were located in the main hospital facility a block away but they didn’t bother to follow-up and simply declared both doctors as not certified. In all instances the claims were denied due to the beneficiary seeing providers who were not certified but no explanation was provided.
[iv] We have suggested to TMA on a number of occasions that they should take the initiative and reopen these claims and continue to process them. The response was that it would cost additional money to correct the claims declined in error which they were not willing to commit.
[v] Mail the letter to International SOS, 2802D-2803A West Tower, Philippine Stock Exchange Center, Exchange Road, Ortigas Center, Pasig City Metro Manila, Philippines. Phone +63 2 687 0999
[vi] The claim number indicates the date a claim was officially entered into the system and claims processing started. The claim number is made up of two parts. Both parts consist of seven numbers and the first part represents the year and Julian date when processing started. In this example, 2010333 0001769 the first four numbers represent the year, in this case 2010. The next three numbers represent the Julian date, in this case day 333rd day of the year. Convert this date to a normal date, 29 November 2010, and compare it to the “Date of Notice” on the EOB.
[vii] WPS normally transmits requests for certification on an individual basis and ISOS responds with a list of providers certified or not certified once a week. Therefore ISOS would first check their files and immediately report a denial based on a previously declined certification request which would cause the response to be received in less than two weeks.
[viii] There is a specific fax number for faxing correspondence: (608)301-2250
[ix] If the physician fee is embedded in a global bill from the hospital and not broken out, unless you identify this in your narrative and allocate a portion of the global bill to the staff physician’s fee it is likely WPS will find the billed amount as over the CMAC and disallow a portion of the claim. The amount allocated will depend on the procedure and the CMAC rates for the specific professional fees for that procedure.